Provider Demographics
NPI:1417960873
Name:STACHURA, VICTORIA RUPPENTHAL (MA, LP)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:RUPPENTHAL
Last Name:STACHURA
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8100 LEA RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-1260
Mailing Address - Country:US
Mailing Address - Phone:952-944-9864
Mailing Address - Fax:952-944-0028
Practice Address - Street 1:9531 W 78TH ST
Practice Address - Street 2:SUITE 340
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3810
Practice Address - Country:US
Practice Address - Phone:952-944-3161
Practice Address - Fax:952-944-0028
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 0855103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6153777OtherUBH
MN61-81168OtherMEDICA
MNON146STOtherBCBS
MN70931OtherUHC